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Urban caregiver empowerment: caregiver nativity, child-asthma symptoms, and emergency-department use.

Introduction: In this study, we examined the associations between caregiver empowerment, child-asthma symptoms, and emergency-department (ED) use in a sample of school-age urban children with asthma. We examined differences in caregiver empowerment, and in the associations among caregiver empowerment, proportion of days with child-asthma symptoms, and ED use as a function of caregiver nativity. Method: Participants for this study were part of a larger longitudinal study and included Latino, African American and non-Latino White urban caregivers and their children with asthma (ages 7-9; N = 130). Caregiver empowerment was assessed within family, asthma services, and community domains. Results: Children whose caregivers reported greater empowerment within the family (i.e., possessing sufficient knowledge and ability to care for their families) presented with fewer asthma symptoms. Children whose caregivers reported greater empowerment within asthma services (i.e., the ability to collaborate with asthma providers and the health-care system), presented with more asthma symptoms. Foreign-born caregivers endorsed greater empowerment within the family, whereas U.S.-born caregivers reported greater empowerment within asthma services. For foreign-born caregivers, higher levels of empowerment in the family were associated with fewer child-asthma symptoms. For U.S.-born caregivers, higher levels of empowerment in asthma services were associated with more child-asthma symptoms. Discussion: Results suggest that caregivers who feel more confident and better able to manage problems within their families may better manage their children's asthma symptoms. Foreign-born caregivers may benefit from increased support to more effectively navigate the asthma health-care system and manage their children's asthma.

Keywords: caregiver empowerment, asthma, disparities, ethnicity

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Asthma affects 9.5% of American children (Akinbami et al., 2012). Black and Puerto Rican children experience the highest asthma prevalence rates (11.2% and 16.1% respectively; Akinbami et al., 2012). Ethnic minority children are disproportionately present in urban settings where child-asthma rates are high (Pearlman et al., 2006; Williams, Stemthal, & Wright, 2009) and there is increased exposure to asthma triggers (Crain et al., 2002). However, asthma can be well-controlled with appropriate outpatient management strategies (National Asthma Education and Prevention Program, Expert Panel Report 3 [NAEPP], 2007).

Ethnic minority and urban children with asthma have higher emergency-department (ED) use rates than non-Latino Whites (Moorman et al., 2012; Shields, Comstock, & Weiss, 2004). Urban and ethnic minority families are less likely to administer preventive care, use a consistent health-care provider, and are more likely to use the ED for child-asthma care (Boudreaux, Emond, Clark, Camargo, & MARCI, 2003; Jandasek et al., 2011; McQuaid et al., 2012; Rand et al., 2000). Individual (e.g., illness severity), health care (e.g., patient-provider relationship), family (e.g., family support), and cultural-related factors (e.g., caregiver nativity) have been associated with urban and ethnic minority families' greater use of the ED for asthma treatment (Flores et al., 2009; KoinisMitchell et al., 2007, 2011; Mansour, Lanphear, & DeWitt, 2000; Rand et al., 2000).

Asthma management involves attention to symptoms, understanding of medications and their administration, avoidance of asthma triggers, and effective communication with healthcare providers (e.g., primary care providers, asthma specialists, school nurses; McQuaid et al., 2005). Caregivers play a significant role in effective child-asthma management. Given the complexity of effective asthma management for urban families (Koinis-Mitchell et al., 2007) and the stressors families may face related to urban poverty (e.g., health-care access, inconsistent use of providers, lack of insurance; Jandasek et al., 2011) and ethnic background (e.g., discrimination, language barriers; Koinis-Mitchell et al., 2011, in press), urban caregivers may be at a greater disadvantage for effectively managing their children's symptoms and navigating the health-care system.

Empowerment is a multidimensional concept that involves individuals gaining knowledge, skills, and resources to enhance their quality of life. It is manifested at the individual, familial, and systemic level (Curtis & Singh, 1996; Feste & Anderson, 1995). Within the health-care context, caregiver empowerment involves caregivers' health-care system knowledge, appropriate disease management and advocacy skills with the goal of supporting children's effective asthma treatment (Aujoulat et al., 2007; Curtis & Singh, 1996; Fitzsimons & Fuller, 2002). Findings in the developmental disabilities and child mental illness literatures highlight the role of caregiver empowerment in supporting positive treatment outcomes, increased parent participation (Banach et al., 2010; Farber & Maharaj, 2005), and satisfaction (Graves & Shelton, 2007; Resendez et al., 2000; Taub et al., 2001) with their children's treatment.

Many ethnic minority caregivers experience mistrust toward the health-care system (Armstrong et al., 2008; Benkert, Peters, Clark, & Keves-Foster, 2006; Boulware et al., 2003). Puerto Rican caregivers, for instance, who reported more severe symptoms of depression, endorsed less empowerment to care for their children's asthma (Martinez, Perez, Ramirez, Canino, & Rand, 2009). Caregivers' empowerment provides the potential to enhance their ability to support their children's asthma management in a health-care context, even if that context is not always receptive to the needs of ethnic minority families.

For caregivers of children with asthma, caregiver empowerment can be developed through increased knowledge of asthma and administration of specific components of asthma management (e.g., response to symptoms and medication administration and timing; Resendez, Quist, & Matshazi, 2000). It includes knowledge of the health-care system (e.g., understanding the role of asthma-care providers and how to appropriately access emergency services), comfort asking questions, and advocating with providers for children's asthma treatment.

Latino caregivers born outside mainland United States reported a greater number of ED visits for their children's asthma than caregivers born in the United States mainland (Klinnert Price, Liu, & Robinson, 2003; Koinis-Mitchell et al., 2011). For foreign-born caregivers, the experience of adjusting to a new country and health-care system may contribute to their decisions about asthma-management strategies and where to seek care for their children (DeRose, Escarce, & Lurie, 2007). Greater empowerment may assist this population in demystifying misconceptions about asthma and its management and supporting effective use of asthma health-care resources (Koinis-Mitchell et al., 2011).

In the current study, we examined the association of caregiver empowerment, proportion of days with asthma symptoms, and ED use in an ethnically diverse, urban sample of children with persistent asthma and their caregivers. We hypothesized caregivers' greater levels of empowerment would be associated with a smaller proportion of days when their children suffered asthma symptoms and fewer ED visits. We examined differences in caregiver empowerment as a function of caregiver nativity, that is, those born within the United States mainland (U.S.-born) compared with those born outside (foreign-born). We hypothesized that U.S.-born caregivers would endorse higher levels of caregiver empowerment than foreign-born caregivers. We sought to explore the association of caregiver empowerment dealing with asthma symptoms and ED use separately in foreign-born and U.S.-born caregivers. We hypothesized that U.S.-born caregivers' greater levels of empowerment would be associated with a lower proportion of children experiencing asthma symptoms and fewer ED visits.

Method

Procedure

The data reported here are part of a longitudinal study, Project NAPS (Nocturnal Asthma and Performance in School), examining the association of asthma and allergic rhinitis, sleep, and academic functioning in urban children with and without a persistent asthma diagnosis. Recruitment of participants occurred in a hospital-based ambulatory clinic, an asthma-education program, and urban school districts. Eligibility criteria included (a) child between 7 and 9 years of age, (b) child's legal guardian participation, (c) parent ethnicity self-defined as Non-Latino White (NLW), Latino, or African American (AA), (d) residency in an urban school district, and (e) child had asthma, or met persistent asthma status, as reported by the caregiver. Asthma diagnoses were confirmed through a clinician evaluation that used guideline-based procedures (NAEPP, 2007). Exclusionary criteria included moderate to severe cognitive impairment, use of stimulant medication for attention-deficit/hyperactivity disorder, intermittent asthma, another pulmonary or chronic health condition, or diagnosed sleep disorder. Participants completed the protocol in English or Spanish according to their preference and received monetary compensation for all study visits. Approval for the study was obtained from the Institutional Review Board of Rhode Island Hospital.

For the present study, only NAPS participants with asthma were included. For the 2 years of this study, 1,248 potential participants were screened for NAPS participation. Of those screened, 72% were ineligible, 2% declined to participate, 5% were eligible but did not enroll (i.e., were not available for follow-up, missed an enrollment visit, became difficult to contact) and 21% were eligible and enrolled. Of those enrolled, some were deemed ineligible after clinician assessment, given no asthma (n = 6) or inconclusive asthma diagnoses (n = 1), and due to other medical issues (n = 16). Each family with a child with asthma enrolled in NAPS participated in this substudy. Recruitment sources included (a) schools (28%), (b) clinic (17%), (c) community asthma program (53%), and (d) other (e.g., word of mouth, 3%). Data for the current study were completed within the first two monitoring periods (each 4 weeks in length), in the fall and winter of the year of participation. Demographic information, asthma symptoms, and ED visits were collected in the first monitoring period (fall), and caregiver empowerment was measured during the second period (winter).

Measures

Demographic Questionnaire. Primary caregivers provided demographic information including the child's age and gender, caregiver and child ethnicity, caregiver country of birth, caregiver-preferred language and family income. Poverty status was categorized as above or below the poverty threshold, and determined by the family's per capita annual income compared to the federal poverty threshold for a same size family (U.S. Department of Health and Human Services, 2005).

Caregiver nativity. Caregiver nativity was defined as foreign-born or U.S.-born.

Caregiver empowerment. The Family Empowerment Scale (FES; Koren et al., 1992) and the Patient Activation Scale (PAS; Alegria et al., 2008; Cretin, Shortell, & Keeler, 2004) were used to conceptualize caregiver empowerment. Both scales were modified to reflect asthma treatment. The FES' overall instructions were modified to direct caregivers to consider asthma services for the past 12 months; items were not changed. The services-domain instructions were modified for caregivers to consider services "related to asthma, asthma education, treatments, plan for school and home." The 34-item FES assesses caregiver empowerment using three subscales: family functioning (Family domain, 12 items, e.g., "When I need help with problems in my family, I am able to ask for help from others."), engagement with asthma providers (Asthma Service domain, 12 items), and advocacy within the community (Community domain, 10 items). Responses were given on a 5-point Likert scale ranging from 1 (never) to 5 (very often). Within this study internal consistency is very good (Cronbach's as = .85, .89, and .88 for Family, Service, and Community subscales, respectively).

The 9-item PAS assesses the patient's engagement in behaviors that increase their collaboration with the health-care provider within a medical encounter, such as question formulation and information-seeking skills (Alegria et al., 2008; Cretin et al., 2004). We conceptualized this measure as assessing caregiver empowerment related to the Service domain of the FES (Koren et al., 1992). Items of the PAS were modified to consider asthma services, for example, "How well do you communicate with your child's asthma doctor when you are feeling uncomfortable about his/her treatment?" Participants chose a response ranging from 1 (none of the time) to 10 (all of the time). Internal consistency was very good for Spanish, English, and for our modified version (Cronbach as = .75, .82 and .81, respectively, Alegria et al., 2008).

Asthma symptoms. Caregivers completed a daily diary in which they noted breathing problems experienced by their children during a 4-week monitoring period. A proportion of days during which asthma symptoms were reported was computed across all days with valid data during the 4-week period. Eighty-seven percent of participants completed at least 2 weeks of diary data (M = 26 days, SD = 5), that is, they provided 2 weeks of valid data. The remaining 13% completed fewer than 2 weeks (M = 9 days, SD = 2) of valid data. We excluded from analyses those participants with fewer than 7 days with valid data; this threshold was based on a prior evaluation of pulmonary function-testing data (Seifer et al., 2009), which indicated that valid estimates of lung function can be based on at least 7 days' data. Analyses nested by case (F = 2.1, p < .001) indicated an association between the data collected in the diary and daily lung-function data, i.e., forced expiratory volume in 1 s (FEV1) collected during the 4-week monitoring period (KoinisMitchell et al., in press).

ED Visits. Caregivers reported the number of asthma-related child ED visits within the previous year. ED visits ranged from 0 (n = 63) to 20 (n = 1; M = .99, SD = 2.19). Most Caregivers reported one (n = 19), two (n = 12) or three (n = 9) ED visits in a year. Given the limited range of visits and standard practice in the asthma literature, ED visits were categorized into none and one or more visits.

Statistical Analysis Plan

Preliminary analyses included examining differences in caregiver empowerment, PAS (Alegria et al., 2008; Cretin et al., 2004), asthma symptoms, and ED use by demographics (i.e., child age, gender, ethnicity, poverty status, caregiver country of birth, and language) using analysis of variance (ANOVA) and chi-square ([chi square]) analysis. This allowed us to determine which variables to control in subsequent analyses. Correlational and [chi square] analyses assessed the simple correlations between the constructs and identified covariates in the regression procedures.

Regression analyses were used to assess the association between caregiver empowerment, child-asthma symptoms, and ED visits. ANOVAs were used to examine differences in caregiver empowerment by caregiver nativity. Regression analyses were completed separately for U.S.-born and foreign-born caregivers to examine differences in the association of caregiver empowerment with asthma symptoms and ED use for each group. A p value of .05 was used to assess the significance of the results. To assess the effect size of the ANOVAs, partial omega squares ([w.sup.2.sub.p]) are reported, and interpreted as small (.01), medium (.06) or large (.14; Cohen, 1988). For [chi square] analyses, Cramer's phi (([[phi].sub.c]) is presented and the adjusted [R.sup.2] is used to assess effect size in regressions.

Results

Sample descriptive data appear in Table 1. The sample included 141 children and caregivers. Child participants were mostly girls (51%) with a mean age of 8.33 (SD = .86). The sample was predominantly Latina, with 51.1% of caregivers self-identifying as Latino/a, 30.7% as AA and 18.2% as NLW. Caregiver country of birth included mainland United States (n = 73), the island of Puerto Rico (n = 25), Dominican Republic (n = 23), and other (n = 16). Most caregivers were U.S.-born (51.8%), and (71.5%) reported household incomes below the poverty threshold. More Latino (43%) families reported incomes below the poverty threshold, [chi square] = 17.92, p < .001. Asthma severity ranged from mild intermittent to severe persistent. Given our interest in ED use, those with mild intermittent asthma (n = 7) and participants with missing data (n = 4) were removed from the main analyses. The main study analyses included 130 participants.

Preliminary Analysis

Patient activation differed by preferred caregiver language, F(l, 120) = 4.2, p = .04; caregivers who preferred English (M = 79.1) reported higher engagement and collaboration with asthma-care providers than caregivers who preferred Spanish (M = 74.4). There were differences in the Service domain of caregiver empowerment, F(l, 120) = 3.9, p = .04, with caregivers who preferred English (M = 4.4) reporting greater ease collaborating with asthma-care providers than those who preferred Spanish (M = 4.2; see Table 2). Those below the poverty threshold (36.2%) were more likely to endorse no ED visits relative to those above (20.8%, [chi square] = 5.63, p = .04) see Table 3. We controlled for poverty threshold and caregiver-preferred language in the main analyses.

Caregiver Empowerment, Child-Asthma Symptoms and ED Use

Stepwise regression was used to examine the contribution of caregiver empowerment to the proportion of days in which child-asthma symptoms occurred. Poverty threshold and caregiver-preferred language were entered in the first step, followed by each of the caregiver empowerment variables (patient activation from the PAS and Family, Service, and Community factors from the FES) entered on separate steps. Empowerment in the Family, [DELTA]F(1, 108) = 8.7 p = .004 and Service, [DELTA]F(1, 107) = 4.7, p = .03 domains added significantly to the model. Greater caregiver empowerment in the Family domain, [beta] = -.53, p < .001, was associated with lower proportion of days with child-asthma symptoms. Greater caregiver empowerment in the Service domain, [beta] = .32, p = .05, was associated with more child-asthma symptom days (see Table 4). Results suggest that when caregivers feel more empowered to address issues within the Family domain, families are also less likely to endorse child-asthma symptoms. Contrary to our hypotheses, caregivers who endorsed greater levels of empowerment when dealing with service providers reported more child-asthma symptoms.

The role of caregiver empowerment in predicting ED visits was examined using stepwise logistical regression. The findings were not significant (see Table 5 for odd ratios).

We examined differences in caregiver empowerment as a function of caregiver nativity. We found differences in patient activation, F(1, 120) = 8.3, p = .005, with U.S.-born caregivers (M = 80.5) reporting higher levels of patient activation than foreign-born caregivers (M = 74.9; see Table 2). U.S.-born caregivers reported engaging in more active collaboration, and information seeking with asthma providers than foreign-born caregivers.

To assess whether the association of caregiver empowerment with proportion of days with asthma symptoms and ED use differed as a function of caregiver nativity, we completed the regression analyses as described above, separately for U.S.-born and foreign-born caregivers (see Table 4). For U.S.-born caregivers, empowerment within the service domain was a significant contributor to the final model, [DELTA]F(1, 54) = 4.9, p = .03, [beta] = .47, p = .01. Contrary to what we expected, results indicate that for U.S.-born caregivers, their ability to collaborate and advocate with asthma care providers is associated with more child-asthma symptoms. For foreign-born caregivers, empowerment within the family domain was a significant contributor to the model [DELTA]F(1, 46) = 5.4, p = .02, [beta] = -.46, p = .04. For foreign-born caregivers, competence and ability to address problems within the family domain were associated with fewer child-asthma symptoms.

To examine the association with ED use, we ran separate logistic regression models for U.S.-born and foreign-born caregivers. The models were not significant (see Table 5), suggesting that caregiver empowerment did not contribute to ED use.

Discussion

Caregiver empowerment includes the caregiver's (a) knowledge of asthma and asthma-management behaviors, (b) knowledge of the health-care system, and (c) comfort advocating for their children's treatment. Caregiver empowerment was assessed using the FES (Koren et al., 1992) across the Family domain (ability to address problems within the family), the asthma-Services domain (ability to advocate and address concerns with asthma providers), and the Community domain (ability to positively impact concerns within their community). Comfort asking questions and collaborating with asthma-care providers within an encounter was included in assessing caregiver empowerment with the PAS (Alegria et al., 2008).

Greater caregiver empowerment in the Family domain was associated with a smaller proportion of days in which children exhibited asthma symptoms. Caregivers with a greater sense of control within their families might feel more confident in managing their children's asthma, using medications as prescribed, and avoiding asthma triggers, which might have resulted in less frequent child-asthma symptoms. Contrary to our hypotheses, greater empowerment within the Service domain was associated with a higher proportion of days with child-asthma symptoms. For children who experience more symptoms, caregivers might have more frequent interactions with asthma-care providers. As a result, caregivers might endorse greater comfort and ability collaborating with providers and advocating for their children's needs.

For U.S.-born caregivers, empowerment within the Service domain was associated with greater proportion of days with child-asthma symptoms. U.S.-born caregivers might feel more comfort advocating for children and collaborating with health-care providers, due to more frequent contact with providers because of the need to control more frequent asthma symptoms in their children. U.S.-born caregivers might be more familiar and comfortable with the medical system and what is expected from caregivers during medical appointments, which might have contributed to their greater empowerment in this domain.

For foreign-born caregivers, empowerment within the Family domain was associated with fewer reported child-asthma symptoms. Foreign-born caregivers, who are likely dealing with an unfamiliar system of care, might experience family as a domain in which they feel more comfortable controlling and making decisions about their children's health. Further, foreign-born caregivers endorsed less comfort when collaborating with service providers and taking on an active role during medical appointments. Although information about the language spoken with asthmatic children's healthcare providers is unavailable, foreign-born caregivers were found to be less likely to speak English, and that may have impacted their comfort level and understanding of health-system encounters and treatment plans. Beliefs about the patient-doctor relationship, for example, a deferent approach to the provider, may impact foreign-born caregivers' expectations about collaboration with providers (Sidora-Arcoleo, Feldman, Serebrisky, & Spray, 2012).

These findings indicate the need for clinical interventions that explore how to enhance caregivers' empowerment within the context of medical encounters. Training providers to develop an atmosphere of collaboration that supports caregiver curiosity and questioning of asthma-treatment decisions may encourage caregiver empowerment. Findings suggest the importance of developing clinical interventions aimed at better understanding caregiver empowerment within the family domain and applying it to strategies in the home that support asthma management (e.g., creating an asthma-friendly bedroom).

Limitations

Given our interest in understanding mechanisms contributing to asthma outcomes in this high-risk population (i.e., urban, ethnically diverse children), the results may not be generalizable to other populations. The sample size is relatively small, particularly for evaluation of associations by caregiver nativity, and this may have impacted our ability to detect meaningful effects. Nevertheless, the significant associations found here indicate that caregiver empowerment and its association with children's asthma symptoms are worthy of further research with larger samples. Although the caregiver empowerment measures have been validated in similar populations, they were adapted specifically for use with this pediatric asthma population. Consequently, there may be aspects of the experience of caregiver empowerment that are not well-captured in this sample. The development of caregiver-empowerment measures specific to child-asthma management is an important next step in research. Additional mechanisms, including caregiver self-efficacy, may contribute to the associations found herein and warrant further study. We did not find an association between caregiver empowerment and ED use. If caregivers perceive asthma as an acute condition that can only be resolved through emergency interventions, their sense of empowerment may not be adequately captured in the literature.

Examining the interaction between caregiver empowerment and barriers to care (e.g., lack of bilingual providers), beyond the caregiver's control is a complex issue that needs further investigation. Results support previous findings highlighting the role of caregiver nativity (Koinis-Mitchell et al., 2011) in child-asthma outcomes. Further study is needed to better understand factors underlying this association, as well as the association between caregiver empowerment and ED use. Future studies with larger samples are needed to better understand the association of empowerment with asthmaservice providers and child-asthma symptoms for foreign-born caregivers. Additionally, it is important to further assess the role of acculturative stress, perceptions of discrimination, as well as beliefs about asthma (e.g., medications, etiology) in the association of caregiver empowerment and child-asthma outcomes.

http://dx.doi.org/10.1037/fsh0000206

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Received October 6, 2015

Revision received April 27, 2016

Accepted May 10, 2016

Maria Teresa Coutinho, PhD, Sheryl J. Kopel, MSc, Brittney Williams, BA, Katie Dansereau, BS, and Daphne Koinis-Mitchell, PhD

Brown University

Maria Teresa Coutinho, PhD, Department of Psychiatry and Human Behavior, E. P. Bradley Hospital, Warren Alpert Medical School, Brown University; Sheryl J. Kopel, MSc, Brittney Williams, BA, Katie Dansereau, BS, and Daphne Koinis-Mitchell, PhD, Department of Psychiatry and Human Behavior, Bradley/ Hasbro Children's Research Center, Warren Alpert Medical School, Brown University.

This research was supported by Grants 3R01HD057220 and 3R01HD057220-03S1 (Daphne Koinis-Mitchell, principal investigator) from the United States Department of Health and Human Services, National Institutes of Health, Eunice Kennedy Shriver National Institute of Child Health and Human Development

Correspondence concerning this article should be addressed to Maria Teresa Coutinho, PhD, Department of Psychiatry and Human Behavior, E. P, Bradley Hospital, Warren Alpert Medical School, Brown University, 1011 Veteran's Memorial Parkway East Providence, RI 02915. E-mail: mcoutinho@lifespan.org
Table 1

Participant Characteristics as a Percentage of the Sample and
Demographic Differences by Parent Self-Reported Ethnic Group

                              Sample       Latino     African American
Study participants          (N = 137)     (n = 70)        (n = 42)

Age, in years M (SD)        8.38 (.86)   8.31 (.86)      8.44 (.86)
Child sex
  Male                          51           25              20
  Female                        49           25              11
Parent language
  English                       74           25              30
  Spanish                       26           25              2
Caregiver nativity
  U.S.-born                     53           15              20
  Foreign-born                  47           36              10
Poverty status
  >poverty threshold            29           8               10
  [less than or equal to]       71           43              21
    poverty threshold
Asthma severity
  Mild intermittent             5            2               1
  Mild persistent               40           22              9
  Moderate persistent           36           19              11
  Severe persistent             19           8               10
ED visits (in 12 months)
  None                         56.9         30.8            13.1
  One or more                  43.1          20             17.7

                            Non-Latino White   [chi square]/F
Study participants              (n = 25)        (effect size)

Age, in years M (SD)           8.44 (.92)
Child sex                                       6.06 * (.04)
  Male                             6
  Female                           13
Parent language                                41.62 *** (.22)
  English                          18
  Spanish                          0
Caregiver nativity                             36.59 *** (.21)
  U.S.-born                        18
  Foreign-born                     1
Poverty status                                 17.92 *** (.11)
  >poverty threshold               11
  [less than or equal to]          7
    poverty threshold
Asthma severity                                  12.09 (.19)
  Mild intermittent                2
  Mild persistent                  9
  Moderate persistent              6
  Severe persistent                1
ED visits (in 12 months)                         5.65 (.03)
  None                            13.1
  One or more                     5.4

Note. For F values, partial omega squares ([[omega].sup.2.sub.p]) are
reported for effect sizes and are presented following the respective
statistic, and for [chi square] analyses, Cramer's phi
([[phi].sub.c]) are reported,
* p < .05. ** p < .01. ** p < .001.

Table 2

Mean Differences in Caregiver-Empowerment Variables by Key
Demographic Variables

                                Family                 F
Demographic                     M (SD)      ([[omega].sup.2.sub.p])

Sample (N = 122)               4.5 (.43)
Poverty threshold                                  .04 (.01)
  Above (n = 33)               4.5 (.44)
  Below (n = 89)               4.5 (.43)
Ethnicity: Latino (n = 63)     4.4 (.45)           1.1 (.00)
  African American (n = 38)    4.6 (.36)
  NLW (n = 21)                 4.4 (.48)
Nativity: U.S.-born (n = 66)   4.5 (.42)           1.3 (.00)
  Foreign-born (n = 56)        4.4 (.44)
Caregiver language                                 3.5 (.01)
  English (n = 89)             4.5 (.40)
  Spanish (n = 33)             4.4 (.48)

                                Service                F
Demographic                     M (SD)      ([[omega].sup.2.sub.p])

Sample (N = 122)               4.3 (.56)
Poverty threshold                                  2.1 (.02)
  Above (n = 33)               4.5 (.42)
  Below (n = 89)               4.3 (.60)
Ethnicity: Latino (n = 63)     4.3 (.59)           1.2 (.01)
  African American (n = 38)    4.4 (.49)
  NLW (n = 21)                 4.4 (.59)
Nativity: U.S.-born (n = 66)   4.4 (.53)           1.9 (.00)
  Foreign-born (n = 56)        4.3 (.58)
Caregiver language                                3.9 * (.02)
  English (n = 89)             4.4 (.52)
  Spanish (n = 33)             4.2 (.65)

                               Community               F
Demographic                     M (SD)      ([[omega].sup.2.sub.p])

Sample (N = 122)               2.8 (.88)
Poverty threshold                                  .39 (.00)
  Above (n = 33)               2.9 (.66)
  Below (n = 89)               2.8 (.95)
Ethnicity: Latino (n = 63)     2.7 (.85)           2.5 (.01)
  African American (n = 38)    3.0 (.89)
  NLW (n = 21)                 2.6 (.87)
Nativity: U.S.-born (n = 66)   2.8 (.90)           .03 (.00)
  Foreign-born (n = 56)        2.8 (.86)
Caregiver language                                 .88 (.00)
  English (n = 89)             2.8 (.92)
  Spanish (n = 33)             2.9 (.76)

                                  PA                   F
Demographic                     M (SD)      ([[omega].sup.2.sub.p])

Sample (N = 122)              77.9 (10.8)
Poverty threshold                                  3.2 (.01)
  Above (n = 33)              80.8 (6.9)
  Below (n = 89)              76.9 (11.8)
Ethnicity: Latino (n = 63)    75.8 (12.6)          2.6 (.03)
  African American (n = 38)   79.7 (8.8)
  NLW (n = 21)                81.1 (6.5)
Nativity: U.S.-born (n = 66)  80.5 (7.8)         8.3 ** (.07)
  Foreign-born (n = 56)       74.9 (12.9)
Caregiver language                                4.2 * (.02)
  English (n = 89)            79.1 (9.4)
  Spanish (n = 33)            74.7 (13.4)

Note. NLW = Non-Latino White; Family, Service, and Community values
from subscales of the Family Empowerment Scale; PA values from
Patient Activation Scale. Partial omega squares
([[omega].sup.2.sub.p]) are presented as the effect sizes for the F
values.

* p < .05. * p <.01. ** p <.001.

Table 3

Differences in ED Use and Proportion of Days With Asthma Symptoms by
Demographic Variables

                               ED use ([section])
                                   percentage        [chi square]
Variable                         with no visits     ([[phi].sub.c])

Entire sample                         45.7
Poverty threshold:
  Above (n = 32)                      20.8           5.43 * (.22)
  Below (n = 77)                      36.2
Ethnicity:
  Latino (n = 56)                     30.8            5.65 (.22)
  African American (n = 31)           13.1
  Non-Latino White (n = 22)           13.1
Nativity:
  U.S.-born (n = 57)                  32.3             .93 (.09)
  Foreign-born (n = 52)               24.6
Caregiver language:
  English(n = 82)                     43.1             .29 (.05)
  Spanish (n = 27)                    13.8

                               Proportion of asthma symptoms
Variable                         ([[section][section]) (SD)

Entire sample                        .13 (.17)
Poverty threshold:
  Above (n = 32)                     .14 (.19) (n = 31)
  Below (n = 77)                     .12 (.17) (n = 83)
Ethnicity:
  Latino (n = 56)                    .13 (.19)
  African American (n = 31)          .12 (.12)
  Non-Latino White (n = 22)          .13 (.18)
Nativity:
  U.S.-born (n = 57)                 .13 (.14) (n = 60)
  Foreign-born (n = 52)              .12 (.20) (n = 54)
Caregiver language:
  English(n = 82)                    .12 (.15) (n = 83)
  Spanish (n = 27)                   .13 (.24) (n = 31)

                                             F
Variable                          ([[omega].sup.2.sub.p])

Entire sample
Poverty threshold:
  Above (n = 32)                         .15 (.01)
  Below (n = 77)
Ethnicity:
  Latino (n = 56)                        .09 (.01)
  African American (n = 31)
  Non-Latino White (n = 22)
Nativity:
  U.S.-born (n = 57)                     .05 (.01)
  Foreign-born (n = 52)
Caregiver language:
  English(n = 82)                        .07 (.01)
  Spanish (n = 27)

([section]) ED use, n = 109. ([section][section]) asthma symptoms,
n = 114, with Latino (n = 60), African American (n = 34), and
Non-Latino White (n = 20).

* p < .05. * p <.01. ** p <.001.

Table 4

Hierarchical Regression Predicting Proportion of Days With Asthma
Symptoms From Caregiver-Empowerment Variables for the Overall Sample,
and for U.S.-Born and Foreign-Born Caregivers

                                         Full Model

Variables                           B     SE B    [beta]

Overall sample (N = 113)
  Constant                          .55   .20
  Poverty threshold                 .01   .04     .02
  Caregiver language               -.01   .04    -.02
  Patient activation                .01   .01     .05
  Family                           -.21   .06    -.53 ***
  Service                           .09   .05     .32 *
  Community                         .02   .02     .08
U.S.-born caregivers (n = 60)
  Constant                          .57   .26
  Poverty threshold                 .03   .04     .10
  Caregiver language               -.10   .09    -.15
  Patient activation               -.01   .01    -.02
  Family                           -.19   .07    -.54 *
  Service                           .13   .06     .48 *
  Community                        -.01   .02    -.06
Foreign Born Caregivers (n = 53)
  Constant                          .64   .34
  Poverty threshold                -.03   .08    -.05
  Caregiver language                .01   .06     .01
  Patient activation                .01   .01     .11
  Family                           -.21   .10    -.46 *
  Service                           .04   .09     .11
  Community                         .05   .04     .20

                                            Full Model

Variables                          [DELTA][R.sup.2]   [R.sup.2]

Overall sample (N = 113)                 .01             .12
  Constant
  Poverty threshold
  Caregiver language
  Patient activation
  Family
  Service
  Community
U.S.-born caregivers (n = 60)            .01             .17
  Constant
  Poverty threshold
  Caregiver language
  Patient activation
  Family
  Service
  Community
Foreign Born Caregivers (n = 53)         .03             .17
  Constant
  Poverty threshold
  Caregiver language
  Patient activation
  Family
  Service
  Community

                                              Full Model

Variables                          Adj. [R.sup.2]   [DELTA]F     F

Overall sample (N = 113)                .07           .62      2.52 *
  Constant
  Poverty threshold
  Caregiver language
  Patient activation
  Family
  Service
  Community
U.S.-born caregivers (n = 60)           .07           .20       1.79
  Constant
  Poverty threshold
  Caregiver language
  Patient activation
  Family
  Service
  Community
Foreign Born Caregivers (n = 53)        .05           1.48      1.50
  Constant
  Poverty threshold
  Caregiver language
  Patient activation
  Family
  Service
  Community

Note. For poverty threshold those above the threshold were coded 1,
below the threshold were coded 0; for caregiver language, Spanish was
coded 1 and English as 0.

* p < .05, * p <.01. ** p <.001.

Table 5

Bivariate Logistical Regression for Emergency
Department Use

Variable                            OR       CI

Overall Sample (N = 123)            --
  Poverty threshold                 .36   .14-.88
  Caregiver language               1.18   .49-2.84
  Patient activation                .98   .94-1.02
  Family                            .54   .13-2.18
  Service                          2.66   .74-9.27
  Community                        1.22   .74-2.02
U.S.-born Caregivers (n = 66)
  Poverty threshold                 .80   .26-2.45
  Caregiver language               1.19   .08-17.43
  Patient activation                .94   .87-1.02
  Family                            .58   .07-4.85
  Service                          4.45   .61-32.42
  Community                        1.25   .64-2.46
Foreign-born caregivers (n = 57)
  Poverty threshold                 .06   .01-62
  Caregiver language               1.69   .49-5.77
  Patient activation               1.01   .95-1.07
  Family                            .65   .08-5.17
  Service                          1.59   .25-9.94
  Community                        1.29   .55-2.98

Note. OR = odds ratio; CI = 95% confidence interval.
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Author:Coutinho, Maria Teresa; Kopel, Sheryl J.; Williams, Brittney; Dansereau, Katie; Koinis-Mitchell, Dap
Publication:Families, Systems & Health
Article Type:Clinical report
Date:Sep 1, 2016
Words:6939
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